The URL can be used to link to this page

Home My WebLink AboutWire Permit - Permits #12518-1 - 72 CAMPION ROAD 7/22/2015 --. _ INNER .,_: M Date. Mm ........... \ NO `� ry DOVER TOWN-OF NO ININ Ilk �` PERMIT Ft R WIRING\ E Ul Ul \\ ..... ..,........ \O\ \\ - ° O� This s certifies that , _s`... gp ........................ \ y,,, Ss1Q�1 toINN of o ryn ........ `\ has 1 thC1i1 �vv�r� g z ndove NO A � u\ X_ ,..... . .... .. .. ....... . \, . ass E 4 O a L . No. �.,... Fee...... ...................... `�" ELECTRICAL hvsPECTOR check # ME, _ \\ \\ Print Form (f1mrnonwea6i,of MaMacka6effi Official Use Only Permit No.4HA---�- o 2epadwnt olJire Sepvice6 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (l,,vb1,mk) APPLICATION FOR PERMIT TO PERFORM ELECTRI L WORK All work to be performed in accordance Arith the Massachusetts Electrical Code(1\4EC�527 C 12- (PLEASE PRINT.LN T R TYPE ALL Date, INFO'0 EVFORMA TTOX) 7 City or Town of: To the lnspec4or oflVires: By this application the undersigned notice o bis or her intention to perforin the elect I work descried be low. Location(Street&N e r) 'Telephone No.�-��11-1-J Owner or Tenant Owner's Address ar Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building RESIDENTIAL Utility Authorization No. Existing Service— Amps Volts Overhead ❑ UndgrdF-1 No.of Meters New Service Amps Volts Overhead❑ U,dg,d ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: BURGLAR ALARM Comeletion of the fiollowing table may be waived by the Inspector offires. No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans ITransformers E'-VA No.of Luminaire Outlets No.of Hot Tubs Generators K-VA Na.of Luminaires Swimming Pool Above Ei In F-1 No.of Emergency Lighting grnd. ❑ 2rad. Battery Units No.of Receptacle Outlets No.of Oil Burners IFIRE ALARMS JNo.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin2 Devices Na.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices Heat Pump No.of Self-Contained No.of Waste Disposers Totals: IlDetectiori/Alerting Devices Municipal El other No.of Dishwashers Space/Area Heating KW Local 0 Connection Security Systems:* No.of Dryers Heating Appliances KW No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW SiZns Ballasts No.of Devices or EgRiyalent . Telecommunications'Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Egj!ivalent . OTHER: Attach additional detail if desired or as required by the Inspector of Fjqres. Estimated Value of Electrical Work: $400. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Z BOND [:1 OTHER. El (specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: BURNUP AND SIMS LIC.NO.:Al 8365 Licensee: CHRISTOPHER J.TREMBLAY Signature LIC.NO.: (Ifapplicab ,enter "exempt"in the license number line.) 4 ---i3V&Tel.No.:413 822 3627._ Address: 57 HARRIS STREET NORTH ADAMS, MA 01247 Alt.Tel.No..561254-8610 — *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. 6 -0e.,L2=Z!J0 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)El owner F-1 ow-ng I sagent. Owner/Agent Telephone Na. PERMIT FEE: $ Signatyre `11iAC"Rf> ERTIFICATE ILIT I SURAN DATE/2015 YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC, NAME: _. TWO ALLIANCE CENTER PHONE SALC. q FMti ,„ ....... 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS-:.,-,-,-.,----- Attn:Atlanta.CertRequest@marsh.com l Fax:212-948-4321 .__.._.._....__._ __INSURER(s�AFFORDING COVEiaAGE -_... NAIC# -- 605106-Cas 14-15 MAS- INSURER A:ACE American Insurance Company 22667 INSURED _,_... ...Mas7ec North America,Inc. -- INSURER B Indemnity Ins Co Of North America 43575 _— 10400 NW 37th Ter INSURER C:Commerce And Industry Ins Co 19410 Dural,FL 33178 __. _ ........ INSURER D INSURER E: NIA N/A .............._.-- INSURER F COVERAGES CERTIFICATE NUMBER: ATL-003355977-01 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE- -ADL7L SUER IMMIDDYYFFE POLICY EXP LTR POLICY NUMBER M/Con/YYYY�MM/DD/YYYY LIMITS A GENERAL LIABILITY XSL G27336589 09/15/2014 09/15/2015 EACH OCCURRENCE _ X $ 1,750,000 P{2EMISE;-(,E o�Ccur _ COMMERCIAL GENERAL LIABILITY g 250,000 -_--._�CLAIMS-MADE ��OCCUR MEDEXP(Any.one ep rson) ��$- SELFIN$URED X SIR $250,000 PERSONAL a ADV INJURY $ 1,750,000 GENERAL AGGREGATE $ 20,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMPIOP ACG $ 6,000,000 �. PRO- � __.._. . .. POLICY LOG $ A AUTOMOBILE LIABILITY ISA H08827667 09/15/2014 09/15/2015 COMBINED SINGLE LIMIT 5,000, .._. _. QQQ __ Eaacci. X ANY AUTO __ BODILY INJURY(Per person) -_._...._-__._.... -_-. ------ .... ----- X ALL OWNED SCHEDULEn BODILY INJURY Per accident $ AUTOS AUTOS ) X �,�11 NON-OWVED PROPERTY DAMAGE �.... ..... _ HIREDAU'iOS AUTOS $ C X UMBRELLA LIAB X BE 15805711 0/111/2114 19/11/2015 5,000,000 [OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DFI RET E NTIO N I $ B WORKERS COMPENSATION WLR C48017010(AOS) 09115/2014 09/15/2015 X WC STATU- OTH AND EMPLOYERS'LIABILITY' ,7Q13Y kIMLT.S... J..EI3 A Y/N WI_R C4801'7022 A .- -0- ANY PROPRIETOR/PARTNER/EXECUTIVE�� ( A,MA) 0911512014 09(15f2015 2,000 QQQ OFFICER/MEMBER EXCLUDED? I_J N/A E.L.EACH ACCIDENT $ (Mandatory in NH) WCU C48017046(FLGA,NC,TX) 09/15/2014 09/15/2015 E.L.DISEASE-EA EM..... If as, ._ _.. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 A Workers Compensation SCF C48017034(WI) 01115/2/14 11115/2015 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Burnup and Sims is included as Additional Insured with respect to the General and Auto Liability policies where required by written contract or agreement.Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION Burnup and Sims SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 800 Douglas Rd,Penthouse THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Coral Gables,FL 33134 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee -11A,14-t,c @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD , mmo ear ofMass hu-#s Department of euGe Safe'y \ \ \SS-00�4 - . » . Cbristopher J Tremblay>. » s%SDouglas R- oad Miami Ft .33134 : { ~ � =/rase» c_m oa! 0410£20W (,oMMojqWEALTH OF MASSACHUSETTS 1 BOARD Of ELECTRICIANS � ISSUES THE FOLLOWING LICENSE AS A REGISTERED MASTER ELECTRICIAN SPEEDWIRE INC CIRRI STOPHER J TREMBLAY Irl-ul 57 HARRIS Si NORTH ADAMS MA 01247-2338 �' y � 8365 A 07/ 1/16 1 6270 � �� The Coninionweafth of MiUsachuseets Department of Industrial Accidengs Office of Investigations 600 Washington Street Boston, MA 021.11 4aGoa Gw www.mass.goi�ldia Workers' Compensation Insurance Affidavit: -,Builders/Contractors/Electricians/Plumbers ADolicant Information Please PKilliligihil Name (Business/Organizatioii/Individual): SPEED WIRE_INC.... ._ Address: -TX- 10400 NW 37TH TERRACE 178 �_61 0 city/state/zip: Phone 4:_ Are you an employer? Check the appropriate box: Type of project(required): 1.0 1 am a employer with 10 4. El I ain a general contractor and 1 6. New construction 2 employees (full and/or part-time).* have hired the sub-contractors 7. Remodeling 1 am a sole proprietor or partner- listed on the attached sheet. T slip and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. EJ We are a corporation and its 10JUElectrical repairs or additions required.] officers have exercised their 3.EJ I am a homeowner doing all work right of exemption per MGL 11.EJ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and.we have no 12.F0 Roof repairs insurance required.] i employees. [No workers' 13.100ther BURGLAR comp. insurance required.] I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. lam an employer that ispiovidiiig workers'e.ompensation insurance fir my employees. Below is the policy and job site information. Insurance Company Name: [I ACE AMERICAN INSURANCE COMPANY WLR C48017022 9-15-15 -------- Policy 4 or Self-ins.Lic.4. Expiration Date: I ALL LOCATIONS Job Site Address: City/State/Zip: ---------____1__------------------- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, I do hereby certif�y un r �Izpains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone 9: Official us only. Do not write in this area, to be completed by city or town off7cial. City or Town: Permit/License ft Issuing Authority(circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phoneg: